DRUG RESISTANCE IN PROTOZOA

An analysis of the development of resistance to proguanil and pyrimethamine in Plasmodium gallinaceum

1. The development of resistance to proguanil and pyrimethamine was studied in a clone of Plasmodium gallinaceum (strain A) derived from a single erythrocytic parasite and maintained by a standard method of serial inoculations in young chicks.

2. The rate of the development of resistance to 0·05 mg./20 g. doses of proguanil was compared in strains maintained by inocula of 5 × 107, 108 and 109 parasites. Some evidence was obtained that the rate of the development of resistance to the drug was related to the numbers of parasites in the inocula.

3. No correlation was observed between the rate of the development of resistance to pyrimethamine and the size of the population of parasites exposed to its action in strains treated with 0·001 g./20 g. doses of the drug and maintained by inocula of 5 × 107 parasites or 109 parasites; but a greater variability was observed in the rate in the strains maintained by the small inocula than in the strains maintained by the large inocula. Resistance appeared to develop sporadically.

4. Some evidence was obtained that strains treated with a high dose of pyrimethamine (0·05 mg./20 g.) might become more sensitive to the drug as a result of treatment. In three experiments the infections were eradicated by the second or third course of treatment with the drug. However, strains which withstood this dose, developed resistance as rapidly, or more rapidly than those treated with 0·001 mg./20 g. doses. There was therefore no evidence from these experiments with pyrimethamine that resistance to the drug could be produced more readily with small than with large doses of the drug.

5. Except for slight variations, resistance to proguanil developed concurrently with resistance to pyrimethamine in strains treated with that drug.

6. In many of the strains, whether treated with proguanil or with pyrimethamine, resistance appeared to develop quite suddenly, but in others it developed more gradually. The pattern of the development of resistance in strains treated with either of these drugs could be explained by the selection of spontaneously occurring mutants, though some of the data suggested that the mutants differed in degree of resistance to the drug.

7. The rate of development of resistance to pyrimethamine was studied in strains derived from primary inocula composed of known numbers of pyrimethamine resistant parasites and 5 × 107 parasites of the untreated strain A. The addition of at least 106 resistant parasites to the inoculum was required to produce an increase in parasitaemia during the subsequent course of treatment with the drug, but the addition of 102 resistant parasites or, in some experiments, fewer than 102 resistant parasites to the primary inoculum was sufficient to produce a heavy parasitaemia during the second serial course of treatment if the strain was maintained by the standard method (p. 496). When these results are compared with the pattern of the development of resistance to pyrimethamine in the strains treated with that drug, it can be concluded that only in one strain was there any evidence that resistant parasites were present in the primary inoculum when it consisted only of parasites of the untreated parent strain. The rate of development of resistance in many of the strains treated with either proguanil or pyrimethamine suggested a mutation rate of a low frequency.

Trypanosoma congolense: manifestation of resistance to Berenil and Samorin in cloned trypanosomes isolated from Zambian cattle

Four Trypanosoma congolense clones derived from a Mumbwa field isolate proved to be resistant to Berenil with a minimum curative dose (MCD) value of 40 mg/kg and to Samorin with an MCD of 4 mg/kg for mice. Two other clones, one being resistant to Berenil with an MCD of 45 mg/kg but susceptible to 1 mg/kg Samorin, and the other being resistant to Samorin with MCD of 16 mg/kg but susceptible to 7 mg/kg Berenil, were experimentally rendered resistant to each of the respective drugs they were susceptible to by subcurative treatments in mice. The original trypanosome strains and their derivative clones were then screened for their sensitivity to Berenil or Samorin. Three clones derived from the Mumbwa isolate were resistant to Berenil, with MCD's of 14 to 28 mg/kg, and to Samorin, with MCD's of 4 mg/kg. A single Mumbwa derivative clone was relatively sensitive to both Berenil with an MCD of 7 mg/kg and to Samorin with an MCD of 2 mg/kg. The reciprocal drug induction results confirmed that although trypanosomes can acquire tolerance to both Berenil and Samorin, no cross-resistance between the two was evident.

Trypanosoma congolense: the in vitro akinetoplastic induction sensitivity assay

Incubation of Trypanosoma congolense in diminazene aceturate (Berenil) or isometamidium chloride (Samorin) induced akinetoplastic (AK) forms in vitro. The AK values (expressed in percent) obtained were found to be useful for rapid assessment of relative drug sensitivities. In susceptible clones, AK forms were induced at all drug concentrations tested, whereas in resistant clones they were induced only at higher concentrations. The Berenil-resistant clone exhibited AK values of 0.9% +/- 0.6%--8.9 +/- 2% at concentrations of 1-100 micrograms/ml at 4-10 h post-inoculation (p.i.), whereas the Berenil-susceptible clone displayed values of 9.3% +/- 13%--19.2% +/- 5% at 0.1-50 micrograms/ml. Motile trypanosomes were not seen at 100 micrograms/ml at 4 h p.i. or at 10 or 50 micrograms/ml at 10 h p.i. The Samorin-resistant clone showed AK values of 0.5% +/- 0.1%--43% +/- 3% at concentrations of 0.1-100 micrograms/ml at 4 and 10 h p.i., whereas the Samorin-susceptible clone exhibited values of 5.3% +/- 2%--45% +/- 4% at 0.0005-100 micrograms/ml. These results were supported by the findings obtained using a mouse infectivity test.

Reduced accumulation of isometamidium by drug-resistant Trypanosoma congolense

The accumulation of the trypanocide isometamidium chloride (Samorin, RMB Animal Health Ltd., UK) by a range of clones of Trypanosoma congolense with varying sensitivity to the drug, was measured by methods based on the fluorescence of isometamidium. Fluorescence microscopy and flow cytometry showed a reduction in drug accumulation by resistant clones. Fluorescence spectrophotometry demonstrated an inverse correlation between the intensity of cell-associated fluorescence and the level of resistance of the clones expressed in vivo. The addition of the metabolic inhibitor SHAM/glycerol to the incubation medium resulted in a reduction of this apparent difference in drug accumulation between the clones; those clones which were sensitive to isometamidium showed a reduction in fluorescence while a percentage increase in fluorescence was observed as clones became more resistant to the trypanocide. These observations may be of value for the in vitro detection of resistant T. congolense populations and may also be used to estimate the mean level of resistance in a given sample. The results also imply that decreased accumulation of isometamidium by drug-resistant clones of the parasite may be responsible for the reduction in sensitivity.

Drug-resistance transfer among rodent plasmodia

A study on transfer of drug resistance between species of malaria parasites was carried out in mixed infections ofP. bergheiandP. vinckei. The biological characters which served as contrasting markers for separation of the two species were the inability of the ‘old’ blood-passaged strain ofP. vinckeito develop in suitable mosquito vectors and its failure to produce parasitaemia in the adult golden hamster. Facility of sporogonic development and cyclical transmission and a pronounced virulence for the adult hamster marked the N.K. 65 strain ofP. berghei.

Development of a maximal and stable resistance to 200 mg/kg pyrimethamine in theP. vinckeistrain was achieved by a gradual increase in drug level in successive blood transfers.

Mixed, simultaneous infections of pyrimethamine-resistantP. vinckeiand sensitiveP. bergheiwere experimentally induced in white mice. Subinoculations of the mixed infection at the height of parasitaemia was carried out in adult hamsters. Suppression of theP. vinckeiinfection in the hamster by innate resistance and the reappearance ofP. bergheiin the blood was noted. Tests with the maximal concentration of pyrimethamine (200 mg/kg) showed the acquisition of drug resistance in some of theP. bergheiinfected hamsters. Persistence of the acquired resistance was demonstrated following fifteen successive blood transfers in the absence of drug pressure and after five cyclical transmissions.

Parallel control experiments with pyrimethamine-sensitiveP. vinckeiandP. bergheiin mixed infections failed to reveal any enhancement in drug resistance. No spontaneous drug-resistant mutant was found in the sensitiveP. bergheiafter exposure to a single course of treatment with the drug, and persistence of parasites in some treated animals was considered as individual variations in host reactions to the drug. This resistance never persisted after blood transfer or cyclical transmission. No loss in drug resistance had been found following transfer of the resistant R strain from mouse to hamster. A marked difference in the course of the plasmodial infection and in the length of survival of mice inoculated with the drug-resistantP. bergheiwas noted following treatment with pyrimethamine in various concentrations. It is suggested that these differences represent a selective action of the drug on a heterogenicP. bergheipopulation, consisting of drug-resistant and drug-sensitive parasites in the blood of the host.

Injection of sonified material from pyrimethamine-resistantP. vinckeiandP. bergheiinto mice inoculated with a drug-sensitiveP. bergheifailed to induce enhancement of resistance to the drug.

The phenomenon of drug-resistance transfer observed under experimental conditions in rodent malaria is viewed in the light of similar phenomena in micro-organisms.

We gratefully acknowledge the assistance rendered by Mr Jerold Sklarsh.

This paper is Contribution no. N 408 from the Army Research Programme on Malaria. The work was carried out under the sponsorship of the Commission on Malaria, Armed Forces Epidemiological Board, and supported in part by the United States Office of the Surgeon General, Department of the Army.

A study of resistance to cycloguanil in Plasmodium gallinaceum in chicks

A cycloguanil-resistant strain of Plasmodium gallinaceum was produced relatively rapidly by passage through chicks treated with low but effective doses of the drug, the dose being increased as resistance developed.

The strain was cross-resistant to proguanil but not to pyrimethamine or chloroquine.

A strain highly resistant to proguanil was resistant to cycloguanil but only slightly resistant to pyrimethamine.

A strain highly resistant to pyrimethamine was resistant to proguanil and cycloguanil.

Passage for 20 months through birds treated with doses of cycloguanil which suppressed infection for relatively long periods failed to change the sensitivity of the strain to this drug or to proguanil. Although the relatively large dose did not eradicate the infection in any of the birds, subinoculations demonstrated that parasites were absent from the blood for a period in some of the birds, though infections finally developed.

I am indebted to Parke Davis and Company for the supply of cycloguanil, to Imperial Chemical Industries Ltd. for the proguanil hydrochloride and chloroquine phosphate and to Burroughs Wellcome and Company for the pyrimethamine base.